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0 IF, <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOfi:OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone. (209) 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. /J!J <br /> 76-6s 9� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7 1 -7Z <br /> (Complete In Triplicate) <br /> Application is 'hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 1/1 20 L 4.4 LR A d � �r CENSUS TRACT <br /> Owner's Name D l L fl f L G .... ....... ... .. . .... . . Phone ,!Z <br /> Address _ 4'e?.20 WAI-4 City _S <br /> Contractor r s Name 4 R 7- ER 12/21 4 License #,A2_ja0 <br /> Ph P zs'" <br /> TYPE OF WORK (Check): NEW'WELL '/Xf DEEPEN -/-7 RECONDITION /-7 DESTRUCTION /7 <br /> PUMP INSTALLATION M. —PUMP REPAIR-/-7—pump REPLACEMENT /7 <br /> Other L_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAE FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC.WELL' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial �(- Cable Tool Dia. of Well Excavation /2 " Rs <br /> Domestic/private Drilled Dia. of Well Casing $ " <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal ro' <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical "-'Surface Seal Installed BY: <br /> _Z4 S. / <br /> PIMP INSTALLATION: Contractor <br /> Type of Pump. r� H.P. I <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP ,REPAIR: / / State Work Done <br /> RE&TRUCTION OF WELL:- Well Diameter Approximate Depth <br /> Describe Material. and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well '-construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of -the well and notify them before putting.the..well. in.use.... The above <br /> information is true to the-best of my`knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNER TITLE <br /> (DRAW-PLOT P N ERSE SIDE <br /> f&4 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 7-2Q?L <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY � ;. DATE q-� Ir -74 INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 Qf75 2M <br />